clinton county government - Susque View

Note to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED. ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING. Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or ...
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EDUCATION Name and Address of School

Course of Study

Years Completed

Diploma Degree

High School

Undergraduate College

Graduate Professional

Other (Specify)

Describe any specialized training, apprenticeship, skills, and extra-curricular activities.

Professional Licenses and Certificates, State of Issue, Expiration Date, and Registration Number.

List professional, trade, business or civic activities and offices held. You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status:

SPECIALIZED SKILLS (Check applicable skills)  MS Word  MS Access  Equipment Operation Please list:

 MS Excel  Other ___________________

 MS Publisher  Other ___________________

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EMPLOYMENT EXPERIENCE Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status. 1.

Employer

Dates Employed From To

Work Performed

Address Telephone Number(s)

Hourly Rate/Salary Starting Final

Job Title Reason for Leaving 2.

Employer

Dates Employed From To

Work Performed

Address Telephone Number(s)

Hourly Rate/Salary Starting Final

Job Title Reason for Leaving 3.

Employer

Dates Employed From To

Work Performed

Address Telephone Number(s)

Hourly Rate/Salary Starting Final

Job Title Reason for Leaving

If you need additional space, please continue on a blank sheet of paper.

VOLUNTEER EXPERIENCE State any additional information you feel may be helpful to us in considering your application.

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Note to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING. Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied? A review of the activities involved in such a job or occupation has been given. _____ YES _____ NO

REFERENCES (No relatives please) 1.

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(Name)

Phone #

(Address)

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(Name)

Phone #

(Address)

3.

( (Name)

) Phone #

(Address)

Pennsylvania state law (Act 13) requires all persons to submit a report of criminal history record information or a statement from the State Police that their repository contains no such information. If you have a current background response, kindly attach it to the completed application. If you do not have a current background check, please be informed that one will be performed upon your acceptance at Susque-View Home. If you are not now, and for the two years immediately preceding this application, have not been, a resident of the Commonwealth of Pennsylvania, you are required to submit with the application for employment a report of Federal Criminal History Record information. Please contact the Human Resource office for further information on how to obtain a background check request.

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APPLICANT’S STATEMENT I certify that answers given herein are true and complete to the best of me knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. This application for employment, if completed in full, shall be considered active for a period of time not to exceed 45 days. Any appli